Report on documentation and evaluation of Urban HEART pilot in … · 2018. 12. 13. · 6 local government officials, educationalists, urban planners, engineers and those who determine

Report on documentation and evaluation

of Urban HEART pilot

in Indonesia

2013

This document was prepared by a team from the Indonesian Epidemiological Association led

by Abdul Muhid Meliala

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Contents

1. Introduction ....................................................................................................................... 4

2. Background to piloting in Indonesia ............................................................................... 5

3. Method used to conduct documentation and evaluation ............................................... 6

4. Process undertaken ........................................................................................................... 7

4.1 Document reviews .............................................................................................................. 7

4.2 Consultative activities ......................................................................................................... 8

4.3 Healthy Cities overview in Indonesia ................................................................................. 9

4.4 Urban HEART contribution to primary health care in urban areas .................................. 10

5. Results of documentation and evaluation ..................................................................... 11

5.1 Pre-assessment phase ........................................................................................................ 11

5.2 Assessment phase ............................................................................................................. 17

5.3 Response prioritization phase ........................................................................................... 27

5.4 Policy development and programme implementation phase ............................................ 29

5.5 Impact and outcome evaluation ........................................................................................ 34

6. Summary of key lessons, impacts and outcomes, and recommendations .................. 35

6.1 Lessons learnt ................................................................................................................... 35

6.2 Key impacts and outcomes of the piloting experience ..................................................... 36

6.3 Recommendations ............................................................................................................. 37

Relevant source materials ..................................................................................................... 38

Annexes

Annex A. Minimum service standards on health at district and city levels

(Ministry of Health Rule No. 741/2008)................................................................. 40

Annex B. Summary of results of focus group discussions on Urban HEART ........................ 41

Annex C. Urban Health Equity Matrix .................................................................................... 44

Figures

Figure 1. Map of City of North Jakarta .................................................................................... 12

Figure 2. Map of City of West Jakarta ..................................................................................... 13

Figure 3. Infant mortality rates: Jakarta, Denpasar and Indonesia (1994–2007) ..................... 25

Tables

Table 1. Population and health administration structure (2009) .............................................. 14

Table 2. Proportion of urban villages with selected organizations, by city (2007) ................. 14

Table 3. Proportion of urban villages with selected health personnel, by city (2007) ............ 14

Table 4. Proportion of urban villages with specific characteristics, by city (2007) ................ 15

Table 5. Health outcome indicators (2007).............................................................................. 15

Table 6. Proportion (%) of population with noncommunicable diseases (2007) .................... 15

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Table 7. Proportion (%) of population with communicable diseases (2007) .......................... 16

Table 8. Health outcome indicators ......................................................................................... 19

Table 9. Disease-specific prevalence ....................................................................................... 19

Table 10. Physical environment and infrastructure indicators ................................................. 20

Table 11. Social and human development indicators .............................................................. 21

Table 12. Economics indicators ............................................................................................... 22

Table 13. Governance indicators ............................................................................................. 23

Table 14. Healthy Settings for dengue haemorrhagic fever control programme ..................... 26

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1. Introduction

Indonesia is the fourth most populated country in the world, after China, India and the United

Stated of America. The national census in 2010 revealed the Indonesian population to be

237.6 million. The annual population growth (according to the census) between 2000 and

2010 was 1.49%, or an increase of around 3.5 million per year. The population of Jakarta is

growing by 1.39% annually, while that of Bali is increasing by 2.15% annually. In 2010 the

urban population reached 52% of the total population. It is estimated that the urban

population will be 65% of the total Indonesia population in 2025. Most of those are living in

the capitals of provinces and other municipalities, including the Jakarta Metropolitan Area,

Surabaya, Yogyakarta, Bandung, Semarang, Medan, Makassar and Denpasar, and other cities

of the outer Java islands.

Administratively, the Government of Indonesia consists of central, province, and district or

municipal levels. Law No. 32/2004 on local government gives autonomous rights to

provinces, districts and municipalities. This means that there are two steps of decentralization

being operated throughout Indonesia: provincial government, and district or municipal

government. The districts and municipalities are categorized as being at the same

autonomous level and are the spearhead of autonomy in Indonesia. Each district and

municipality consists of subdistricts that are further divided by village (desa or kelurahan).

Throughout Indonesia, there are 33 provinces with 98 cities and 399 districts, further

subdivided into 6543 subdistricts and 75 226 villages (Ministry of Interior 2009 and 2011

figures).

The impact of urbanization on population health, health equity and the environment has

become of important concern for city and national authorities. The rapid shift from a rural

subsistence economy to an urban, market-oriented and industrial economy also brings a range

of urban health problems, including environmental health problems.

For a long time it has been observed that the health status of the urban poor is lower than for

other urban communities. The infant mortality rate and the mortality rate of children under 5

years among low-income groups is about four times higher than among high-income groups.

The poor environmental conditions, including low-quality housing and shortage of clean

water and basic sanitation facilities, make the situation worse, and add to the social and

economic inequality among urban families. Unemployment and underemployment also

aggravate the financial and economic situation, and there is a shortage of public resources to

mitigate poverty and improve the physical infrastructure and social services.

The Urban Health Equity Assessment and Response Tool (Urban HEART) was developed by

the World Health Organization (WHO) in 2008. It aims to equip policy-makers with the

necessary evidence on which to base strategies to reduce inter-city and intra-city health

inequities. The tool was designed as a user-friendly guide for decision-makers at national and

local levels to help analyse inequities in health between people living in various parts of cities

or belonging to different socioeconomic groups within and across cities. It is also intended to

facilitate decisions on viable and effective strategies and interventions to reduce health

inequities.

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Indonesia was selected as one of the pilot countries for the application of Urban HEART in

2009. Jakarta and Denpasar were selected as the implementation sites. The processes,

mechanisms and achievements of the Urban HEART implementation in Indonesia need to be

documented and evaluated. This will provide the basis for continuous improvement of the

tool, and will assist in advocating its use and creating greater consciousness to promote urban

health equity.

The technical documentation and evaluation results, targeted for wide dissemination, will be

useful for stakeholders in other urban areas to become familiar with Urban HEART and

eventually utilize the tool to address health differentials and socioeconomic determinants of

health. It is envisioned that the expansion of the use of Urban HEART in different cities and

countries will contribute to the broader goal of applying an equity perspective in health and

development work, with the end goal of narrowing inequities in health.

2. Background to piloting in Indonesia

Indonesia, in common with other developing countries, has experienced a rural to urban shift

in population. At present the urban population of Indonesia has reached over 50% of the total

population, and is mainly found in the capitals of provinces and districts as well as in

municipalities. In 2009, there were 98 cities (19.7%) out of 497 districts (all districts + cities)

that were categorized as autonomous areas in Indonesia.

The main cause of rapid urbanization in Indonesia is rural-urban disparities. Urbanization

cannot totally be avoided due to strong urban pull factors, including socioeconomic factors,

the availability of public services such as health and education, and job opportunities in urban

areas. Therefore, centres for socioeconomic development need to be created in rural areas or

outside cities in order to reduce the rural push and urban pull trend. To help cope with the

problems of urbanization, Indonesia is developing a Master Plan for Fostering and Expanding

Economic Development. Efforts will be made to develop infrastructure in the first stage of

the plan, which aims to reduce rural-urban disparities.

The impacts of urbanization on population health, health equity and the environment have

become important concerns of city and national authorities. The rapid shift from a rural

subsistence economy to an urban, market-oriented and industrial economy also brings a range

of urban health problems, including environmental health problems.

Urban HEART is a tool to provide policy-makers and key stakeholders at national and city

levels with a guide to assess and respond to urban health inequities. It assists in identifying

and analysing differences in health opportunities between people living in different cities and

in different parts of cities, as they affect people in different socioeconomic groups. It also

helps to plan interventions and implement effective strategies to reduce inter-city and intra-

city health inequalities.

Urban HEART was piloted in three sites in Indonesia: the City of West Jakarta and the City

of North Jakarta (Jakarta Special Province) and the City of Denpasar (Bali Province).

Urban health is a complex issue because the solutions to health challenges in towns and cities

do not lie within the health sector alone but also with decisions made by others, including

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local government officials, educationalists, urban planners, engineers and those who

determine physical infrastructure and access to social and health services. These

professionals have to face the challenges of overloaded water and sanitation systems,

polluting traffic and factories, lack of space to walk or cycle, inadequate waste disposal,

crime and injury.

Nevertheless, solutions exist to tackle the root causes of urban health challenges. Urban

planning can promote healthy behaviour and safety through investment in active transport,

designing areas to promote physical activity and passing regulatory controls on tobacco and

food safety. Improving urban living conditions in the areas of housing, water and sanitation

will go a long way to mitigating health risks, as will building green, inclusive cities that are

accessible, healthy and bestow age-friendly benefits on all urban residents. The Healthy

Cities programme emphasizes the need for community participation in the decisions that

affect people’s lives.

3. Method used to conduct documentation and evaluation

The method use for documentation and evaluation was as follows:

1. Document reviews undertaken, including report of pilot area, updated Urban HEART

manual produced by WHO Kobe Centre, Healthy Cities programme.

2. Consultative meeting held with a number of government representatives, including

Jakarta and Denpasar officials, and with other related stakeholders and WHO experts.

3. Field observation of Urban HEART pilot implementation in North Jakarta, West

Jakarta and Denpasar, along with discussion with concerned stakeholders and

coordination and steering committee, focusing on activities undertaken before, during

and after assessment.

4. Site visit and pictures taken.

5. Updating data and information and analysing them according to Urban HEART

indicators and response tools.

6. Discussion about the implementation stage, including constraints and possible

measures for improvement, with field implementers and decision-makers.

7. Organize meeting with stakeholders for review and study leading to identification of

necessary actions to be taken for better Urban HEART implementation.

8. Writing report based on findings and discussions.

9. Finalize complete report along with the summary and recommendations for

enhancement of government and stakeholder commitment at central, provincial and

city levels on Urban HEART implementation.

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4. Process undertaken

4.1 Document reviews

A review was made of the written report of the application of Urban HEART in the pilot

areas of West Jakarta, North Jakarta and Denpasar in 2009. The 29-page report was presented

in Nairobi in 2009 by the former Urban HEART pilot team led by Dr Suarta Kosen, a senior

researcher of the National Institute of Health Research and Development, Ministry of Health,

Jakarta.

The report was comprehensive and concise and followed the Urban HEART guidelines

provided by the WHO Kobe Centre. The report covered the process of Urban HEART

application at three cities using community health data from various surveys by the National

Institute of Health Research and Development and the Central Bureau of Statistics, and from

other sources such as the Demographic and Health Survey and the Basic Health Survey

(Riskesdas) of the National Institute of Health Research and Development.

Urban HEART was introduced in three cities in Indonesia in 2009, and provided several tools

with the potential to reduce health inequities in urban settings. Prior to introduction of Urban

HEART, Indonesia has been developing several policies and undertaking strategic

approaches to deal with health equity, including:

Health for All by the year 2000 (HFA/2000), a goal introduced by the International

Conference on Primary Health Care, Alma-Ata, 1978, and since developed by WHO

and subsequently adopted by the Government of Indonesia.

The WHO Healthy Public Policy initiative, adopted by Indonesia on 1 March 1999.

Launch of the Policy on Healthy Indonesia, 2010.

Decentralization Policy of Indonesia, adopted in 1999 and formalized in Law No.

32/2004.

Implementation of the Healthy Districts and Healthy Cities initiatives by Decree No.

34 of the Ministry of Home Affairs and Decree No. 1138 of the Ministry of Health in

2005.

Based on the above-mentioned policies, Indonesia has developed a policy for

implementation of minimal service standards for health, as a basis for action in

following up and achieving the Healthy Indonesia 2010 targets.

Indonesia is also engaged in measures to achieve the Millennium Development Goals

(MDGs), and is committed to achieving their targets by the year 2015.

As a WHO Member State, Indonesia is committed to the organization’s policies and

strategies. For instance, Indonesia aligns with the principles of the Alma-Ata Declaration and

Health for All, and health equity has become a subject of national and subnational concern.

Efforts have been made to enhance access to health services and improve their quality. Issues

relevant to HFA/2000 will be explored within Indonesian health settings in the years to come,

including revitalization of primary health care.

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With regard to endeavours to enhance intersectoral collaboration in health, the Healthy Public

Policy was declared as a strategic policy by President B.J. Habibie of Indonesia on 1 March

1999. This aimed to stimulate various strategic actions on related health developments,

including the Healthy Cities initiative, the Adipura Clean City programme to achieve healthy

and clean cities and resolve environmental health issues, development of primary health care

for slum and poor settlements, and universal immunization coverage.

To ensure the achievement of the Healthy Indonesia goals by the year 2010, Indonesia

declared that minimal health services be provided for populations by district and city health

offices as part of the National Decentralization Policy. Each district and city health office has

responsibility to provided minimal services for all the population in its area. Currently, there

are 18 services to be provided by the health service at district and city levels (annex A).

4.2 Consultative activities

The following consultative activities took place with health officials and stakeholders in

different organizations at the beginning of the process of documentation and evaluation of the

Urban HEART pilot.

Consultations with WHO

At the commencement of the documentation and evaluation of Urban HEART, activities

undertaken included preliminary consultation with the WHO officials dealing with Urban

HEART. It was agreed that the documentation and evaluation assignment would be based

mainly on the experiences of pilot implementation of Urban HEART in the City of North

Jakarta, City of West Jakarta, and Denpasar City. It was also agreed that the Urban HEART

pilot implementation would be documented and evaluated according to the terms of reference

provided by WHO through the APW mechanism. Efforts should be made to document all

important matters on the assessment of health equity and health inequity, based on health

outcome issues and health determinants within the four policy domains, namely physical

environment and infrastructure, social and human development, economics, and governance.

Responses to the assessment results would then be formulated. Matters that needed to be

documented and evaluated included degree of implementation, what policies and strategies

had been developed, the actions that had been carried out, what obstacles were faced and

further steps to be undertaken.

Consultations with Ministry of Health

The documentation and evaluation team held discussions with the Environmental Health

Director (Director-General of Disease Control and Environmental Health), Ministry of

Health. This directorate unit is responsible for managing, and for monitoring and evaluating,

the environmental health programmes, including the Healthy Cities programme.

Generally, the unit is more familiar with the Healthy Cities approach than the Urban HEART

approach. However, they are interested in taking advantage of Urban HEART to improve

health equity as part of an integrated approach in line with the Healthy Cities movement.

Healthy Cities programmes have been promoted by WHO since 1986, and “Healthy Cities

for better life” was the theme of the 1996 World Health Day. In 1998, a Healthy Cities pilot

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project was launched by the Ministry of Home Affairs in six cities in Indonesia, namely

Cianjur, Balikpapan, Bandar Lampung, Pekalongan, Malang and East Jakarta. Further action

was undertaken to developed healthy tourist areas at eight locations – Anyer, Baturaden, Kota

Gede, Brastagi, Senggigi, Bunaken, Tana Toraja, and Nongsa Point and Marina (Batam

Island). These healthy city and healthy special area developments are in line with the Healthy

Public Policy launched in 1999 to help achieve the goals of Healthy Indonesia 2010.

In addition, the documentation team visited the Subdirectorate of Healthy Cities and Sport at

the Ministry of Health to discuss matters related to Urban HEART. The unit is responsible

for organizing and facilitating Healthy Cities programmes throughout the country, according

to the new structure of the Ministry of Health. Unfortunately the subdirectorate was not well

informed about the pilot implementation of Urban HEART in Jakarta and Bali, though the

guidelines for Urban HEART had been circulated through the website by WHO and the

report of the previous assessment team for Jakarta and Denpasar has been submitted to the

unit for its view and comments.

An overview meeting on implementation of Urban HEART in Jakarta, with emphasis on the

cities of West Jakarta and North Jakarta, took place at the Provincial Health Office on 7

September 2011. The meeting was attended by intersectoral officials from the City of Jakarta,

including officials from the Special Province of Jakarta and from North and West Jakarta.

Offices represented included the Regional Development Planning Agency (Bappeda),

Division of Social Welfare, Bureau of Governance, Disease Control Unit, Environmental

Health Unit and Health Promotion Unit.

The meeting recognized that Urban HEART was very relevant to the Healthy Cities

programme and other urban health initiatives. Many healthy city activities had been

undertaken in line with Urban HEART without the back-up of written evidence, clear target

setting and a timeframe for implementation. The results of the meeting can be seen in the

assessment component related to stakeholder engagement.

4.3 Healthy Cities overview in Indonesia

While Urban HEART is a newly introduced tool for health equity improvement in urban

areas, the Healthy Cities programme has been implemented in most cities throughout

Indonesia since 1999. As a tool for health equity, Urban HEART is very much related to the

Healthy Settings approach, of which Healthy Cities is an example. The approach embraces a

wide range of settings, including cities, districts and public environments (for example

schools). According to Indonesian Health Law No. 36, 2009, the Government of Indonesia is

responsible for planning, managing, implementing, guiding and controlling implementation

of affordable health provisions for the whole population, which can only be achieved by

taking account of health equity.

The WHO Healthy Cities programme is a global movement that emerged in response to the

deteriorating health conditions linked with urbanization. The WHO Healthy Cities

programme was launched in the South-East Asia Region in 1994. The programme aims at

realizing its objectives through partnerships between public, private and voluntary agencies.

It engages local governments in health development through a process of political

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commitment, institutional change, capacity building, partnership-based planning and

innovative projects. Health is the business of all sectors, and local governments are in a

unique leadership position, with power to protect and promote their citizens’ health and well-

being.

The Healthy Cities movement promotes comprehensive and systematic policy and planning

for health and emphasizes the need to address inequality in health and urban poverty; the

needs of vulnerable groups; participatory governance; and the social, economic and

environmental determinants of health. It is not only concerned with the health sector, but

includes health considerations in economic spheres and in regeneration and urban

development efforts.

The concept of Healthy Cities in Indonesia is an integral part of health system strengthening.

A healthy city aims to achieve clean, comfortable, safe and healthy living and working

conditions for the benefit of its people. This can be realized through the implementation of a

wide range of integrated activities, as agreed upon by community and local government. A

healthy city also contains healthy areas and healthy villages within its boundaries.

At city level, a healthy city project should include a community forum to facilitate

community involvement and take account of people’s aspirations. The forum would enable

the community to contribute inputs in providing direction, deciding on priorities, and

developing an integrated plan to achieve healthy city objectives. At subdistrict level,

establishment of a village communication forum could support the coordination, integration

and synchronization of health-related activities, including through inter-village cooperation.

The forum, or similar working group, could assist in organizing community efforts for

economic, social, cultural and health development at village level.

Given the integrated nature of these programmes and activities, it is strongly recommended

that a Healthy Settings Committee be set up at city level. One of its main functions would be

act as a steering committee for the implementation of Urban HEART.

4.4 Urban HEART contribution to primary health care in urban areas

A consultative meeting to prepare guidelines for primary health care implementation in

suburban slum areas was held at the Hotel Lor Inn, Sentul Bogor, 8 September 2011. The

meeting was organized by the Ministry of Health under the auspices of the Director-General

of Nutrition and Maternal-Child Health, who has responsibility for policies and strategies and

for the provision of guidelines to ensure the implementation of urban health in Indonesia. The

steering committee for the consultative meeting invited a WHO representative to present the

concept of Urban HEART to assist preparation of the proposed guidelines. The meeting was

attended by 35 key officials, mostly from the Ministry of Health and also representing the

Ministry of Public Works, National Planning Board, Ministry of Interior and National Family

Planning Board.

The representative of WHO, outlining the concept of Urban HEART at a plenary session,

explained why Urban HEART mattered, how it was implemented and what were the

expectations. Information was also given on the Indonesian experience in application of

Urban HEART in the pilot areas – North Jakarta, West Jakarta and Denpasar – including

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elaboration of the two components of Urban HEART, namely the assessment component and

the response component. The health equity assessment component used health outcome

indicators and health determinant indicators covering four main policy domains – physical

environment and infrastructure, social and human development, economics, and governance.

From the outcomes of the exercise, five main response strategies were proposed to deal with

health inequities:

Organize health inequity issues within intersectoral programmes

Concentrate on urban poor as the target for primary health care interventions

Focus health equity measures on urban settings

Enhance capacity to respond to health inequity locally

Develop national health-oriented urbanization policies.

The consultative meeting agreed that Urban HEART was a useful tool in developing primary

health care and health equity improvement interventions, particularly in slum and suburban

areas of a city. The meeting agreed that the Urban HEART concept be incorporated into the

guidelines for primary health care implementation in suburban and slum areas, as a useful

tool in counteracting health inequity. The participants urged that the Urban HEART concept

be widely disseminated to all (98) cities throughout Indonesia, reflecting the commitment of

officials and stakeholders at national level to incorporate Urban HEART into the Healthy

Cities programme in the country. The indicators selected for implementation of the project in

2009 had been assessed in the evaluation process and the decision was made to retain them

unchanged. The meeting also recognized that intersectoral collaboration was the key to

successful implementation of the primary health care programme in urban slums.

5. Results of documentation and evaluation

5.1 Pre-assessment phase

The Urban HEART pilot was implemented at three sites in Indonesia: City of West Jakarta

and City of North Jakarta (Jakarta Special Province) and City of Denpasar (Bali Province).

An assessment team was established in carrying out the Urban HEART pilot.

The general objective of the pilot activities was to improve the health and social status of the

urban population, with a focus on vulnerable and disadvantaged people, through intersectoral

action and social participation.

The specific objectives were as follows: to identify and analyse gaps in health outcomes and

opportunities between people living in different parts of cities, or belonging to different

socioeconomic groups within cities or among cities; and to facilitate policy decisions on

viable and effective strategies, resource allocations, interventions and actions to reduce intra-

and inter-city inequities in health outcomes, access and determinants.

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Orientation of pilot sites

City of North Jakarta

The Special Province of Jakarta, capital of the Republic of Indonesia, is located in the north-

west of Java island. It has an area of 650 square kilometres and a population (2009) of around

9.2 million, giving a population density of over 14 000 persons per square kilometre. About

11.5% of the population has never attended school. There are five municipalities and one

district (Pulau Seribu) in Jakarta, as well as 44 subdistricts and 267 villages.

North Jakarta (figure 1) covers a coastal area of 134 square kilometres and extends around 35

kilometres from west to east. The height above sea level is generally less than 2 metres, and

in several swampy areas the height is below sea level. As a result, the area is subject to

flooding due to overflowing rivers or high tides. The average annual temperature is 28.9°C

and annual rainfall is about 200 millimetres.

Utilization of land in North Jakarta is as follows:

Housing 52.7%

Industry 15.3%

Offices and commercial 10.4%

Vacant land, farms, other uses 21.6%

The City of North Jakarta is divided into 7 subdistricts and 35 urban villages (kelurahan),

with a total population of about 1.2 million, and a population density of nearly 9000 per

square kilometre.

Figure 1. Map of City of North Jakarta

City of West Jakarta

West Jakarta (figure 2) is an old part of Jakarta with many ancient buildings. It is about 128

square kilometres in extent. Average temperatures are relatively high. Land utilization is as

follows:

Housing 52.5%

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Industry 13.4%

Offices and commercial 9.8%

Agriculture 8.3%

Vacant land, other uses 16.0%

The city is divided into 8 subdistricts and 56 urban villages (kelurahan). The total population

is around 2.22 million, and the population density is over 17 000 per square kilometre.

Figure 2. Map of City of West Jakarta

City of Denpasar

Denpasar is located in the southern part of Bali island, with an average height of about 500

metres above sea level. The coastal zone, parts of which are mangrove forest, is around 11

kilometres length. The average monthly rainfall ranges from 1 millimetre (September) to 437

millimetres (January), with average temperatures ranging from 22.7°C to 33.9°C. Irrigated

rice fields occupy 21.3% of the city area. The main economic activities of Denpasar are

related to tourism and include trades, hotels, restaurants and transport.

Administratively, Denpasar consists of 4 subdistricts and 43 villages. It has an area of 127.8

square kilometres and a total population of 629 000, giving a population density of nearly

5000 per square kilometre. The population defined as “poor” numbers 15 646, or around

2.5% of the total. Many of the poor are originally derived from the islands of Java or

Lombok, and come to Denpasar to earn a living, for example as construction workers.

General characteristics of pilot cities

Tables 1–7 present data and information relevant to the Urban HEART pilot project

undertaken in the three pilot cities.

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Table 1. Population and health administration structure (2009)

Variable North Jakarta West Jakarta Denpasar

Population 1.2 million 2.22 million 629 000

Density per sq. km 9000 17 000 5000

Subdistricts 7 8 4

Villages 35 56 43

Hospitals 17 21 18

Health centres 49 75 11

Table 2. Proportion of urban villages with selected organizations, by city (2007)

Type of PVO/NGO

West Jakarta

(%)

North Jakarta

(%)

Denpasar

(%)

Moslem religious group / majelis ta’lim 100.0 100.0 79.1

Christian religious group 78.6 71.0 37.2

Foundation for burial ceremony 66.1 64.5 100.0

Other PVOs 58.9 93.5 58.1

Note: PVO = private voluntary organization; NGO = nongovernmental organization.

Source: Village potency survey, Statistical Office, 2007.

Table 3. Proportion of urban villages with selected health personnel, by city (2007)

Type of personnel West Jakarta (%) North Jakarta (%) Denpasar (%)

Male physician 94.6 96.8 93.0

Female physician 85.7 93.5 86.0

Dentist 75.0 61.3 74.4

Midwife 94.6 93.5 97.7

Other 32.1 19.4 58.1

Traditional healer 39.3 67.7 7.0

Source: Village potency survey, Statistical Office, 2007.

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Table 4. Proportion of urban villages with specific characteristics, by city (2007)

Characteristic

West Jakarta

(%)

North Jakarta

(%)

Denpasar

(%)

River crossing slum area 58.9 77.4 37.2

Households living at riverside 12.5 51.6 62.8

Households living near high-voltage electricity 19.6 35.5 18.6

Active integrated service post 91.1 93.5 93.0

Table 5. Health outcome indicators (2007)

Indicator Jakarta Denpasar Indonesia

Life expectancy at birth (yrs)

Male 71.3 69.0 64.2

Female 75.1 72.9 68.1

Infant mortality rate (per 1000 live births) 28 34 34

Under-5 mortality rate (per 1000 children under 5) 36 38 44

Maternal mortality rate (per 100 000 live births) – – 228

Sources: National Human Development Report, 2004; Demographic and Health Survey, 2007.

Table 6. Proportion (%) of population with noncommunicable diseases (2007)

Disease West Jakarta North Jakarta Denpasar Indonesia

Neoplasm 3.8 8.7 0.5 4.3

Diabetes 1.5 1.4 1.4 1.1

Heart disease 0.6 2.0 0.4 0.9

Hypertension (measured) 23.8 28.7 25.8 31.7

Stroke 8.1 1.0 0.3 6.0

Mental illness 0.3 1.8 0.1 4.6

Mental emotional disorder 11.0 14.0 3.7 11.6

Source: Basic Health Survey (Riskesdas), 2007.

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Table 7. Proportion (%) of population with communicable diseases (2007)

Disease West Jakarta North Jakarta Denpasar Indonesia

Acute respiratory infection 9.1 10.7 1.0 8.1

Pneumonia 0.3 0.5 0.3 0.6

Tuberculosis 0.4 1.1 0.2 0.4

Diarrhoea 6.3 10.2 4.2 9.0

Source: Basic Health Survey (Riskesdas), 2007.

Engagement of national and local government officials

National officials engaged during the pre-assessment phase were from the Directorate of

Environmental Health, Directorate-General of Disease Control and Environmental Health,

Subdirectorate of Healthy Cities and Sport, Directorate-General of Nutrition and Maternal-

Child Health, and Ministry of Health. As mentioned above, Urban HEART was accepted in

principle as a tool to help implement the Health Settings and Healthy Cities programmes,

which are important health development programmes at national level. Implementation

guidelines for the Healthy Districts and Healthy Cities initiatives were issued as Ministry of

Interior and Ministry of Health Regulation No. 34/2005 and No. 1138/Menkes/PB/VIII/2005.

Organization of local technical working group

The Healthy Cities programme was implemented through various activities with community

involvement facilitated by local government through forums or community organization

structures. The forums were instituted as working groups at different levels – village,

subdistrict and city. In accordance with the above-mentioned Ministry of Interior and

Ministry of Health regulation, each city should establish a steering committee for

synchronization of community demand in line with local development and planning. The

team leader was to be the head of the local government planning body, with members from

all related units. The steering committee would be established by the decree of the mayor.

The existing Healthy Cities Committee was the focal point for Urban HEART pilot

implementation. The National Institute of Health Research and Development, the Ministry of

Health, and the Urban HEART Reporting Committee were represented on the Healthy Cities

Committee. City officials engaged in the process came from the Regional Development

Planning Agency (Bappeda), Division of Social Welfare, Ministry of Public Works, Health

Office, City Health Council, Centre for Health Systems and Policy Research and

Development, and private voluntary organizations working on behalf of the urban poor.

The committee was responsible for overseeing and guiding implementation of Urban HEART

and for ensuring the quality of the final assessment and response reports. The committee also

proposed the budget and other resources to the city government.

17

Resources used

Budgetary resources for the Healthy Cities initiative are provided by local government. The

implementation of Urban HEART will, of course, stimulate new demand for the budgetary

resources required for follow-up action based on the findings and recommendations.

However, information on Urban HEART has to be properly disseminated to ensure that

policy-makers are aware of the benefits and to ensure commitment to the tool at local

government level.

Facilitating factors

Identification of facilitating factors during the pre-assessment stage was not straightforward.

As the issue of health equity is cross-cutting in a number of programmes, support from local

government was part of the overall facilitation provided for existing development

programmes.

Hindering factors

The Urban HEART concept has not been widely disseminated among sectors where health

inequity is an issue. There has been no special effort or budget provided for dissemination of

the tool by local government. This may be due to insufficient efforts to accelerate the use of

the Urban HEART concept.

Lessons learnt

It was found that the Urban HEART framework could be applied and used for existing

healthy city projects, for instance through use of the self-assessment survey as a tool to

determine health inequity problems at community level. The term “Urban HEART” tended to

be misunderstood by stakeholders and the community.

5.2 Assessment phase

Stakeholder engagement

The consultative meeting dealing with the Urban HEART pilot took place at the provincial

Health Office, Jakarta. The objective of the meeting was to obtain information regarding the

previous Urban HEART pilot that had been carried out in West Jakarta and North Jakarta in

order to document and evaluate the overall application of the tool. The meeting was chaired

by a senior health officer of the Directorate-General of Disease Control and Environmental

Health, Jakarta City. The meeting was attended by intersectoral stakeholders, including

officials from the Regional Development Planning Agency (Bappeda), Bureau of

Governance, Division of Social Welfare of Jakarta, Provincial Health Office, and Indonesian

Epidemiologist Association.

During the course of the meeting, those attending were informed of the definition and scope

of Urban HEART, and its background, objectives and main elements. In addition, the main

components were outlined, namely the assessment and response and prioritization phases,

and information provided on health determinants and health outcome indicators, within the

18

four policy domains that encompass the key determinants of health: physical environment

and infrastructure, social and human development, economics, and governance.

The main outcomes of the consultative meeting were as follows:

Participants recognized that Urban HEART was a useful tool for policy-makers to

improve health equity based on robust evidence. Use of Urban HEART can help

ensure the effectiveness and efficiency of health equity efforts.

The use of Urban HEART for improving health equity, especially through

intersectoral collaboration, is straightforward and simple, and adds to the

understanding of health-related sectors of health issues.

The tool is very relevant to the Healthy Cities and Healthy Settings programmes, also

initiated by WHO.

However, many activities have been undertaken in line with Urban HEART without

the back-up of written evidence, clear target setting and a timeframe for

implementation.

Since Urban HEART is accepted as a positive tool for improving health equity,

efforts should be made to ensure the correct mechanisms and procedures are applied.

In-depth assessment of the implementation of Urban HEART will be made at the next focal

group discussion among stakeholders and implementers of health-related issues in the city of

Jakarta.

Indicator selection

During the course of pilot implementation of Urban HEART, indicators were selected for

analysing the current health equity situation and making recommendations, on the basis of

the results of the health equity assessment, on appropriate responses to rectify health inequity.

The key health outcome indicators used were:

Life expectancy at birth

Infant mortality rate

Under-5 mortality rate

Maternal mortality ratio

Disease-specific prevalence.

The status of health outcome indicators is presented in tables 8 and 9.

19

Table 8. Health outcome indicators

Jakarta Denpasar Indonesia

2007 2010 2007 2010 2007 2010

Life expectancy at birth

(years) 73.0 69.3 69.2

Male 71.3 n.d. 69.0 n.d. 67.9 n.d.

Female 75.1 n.d. 72.9 n.d. 71.9 n.d.

Infant mortality rate (per

1000 live births) 28 n.d. 34 n.d. 34 n.d.

Under-5 mortality rate (per

1000 children under 5) 36 n.d. 34 n.d. 44 n.d.

Maternal mortality ratio

(per 100 000 live births) _ n.d. _ n.d. 228 n.d.

Sources: Intercensal Population Survey (SUPAS), 2005; Indonesia Demographic and Health Survey, 2007;

BPS, 2009.

Table 9. Disease-specific prevalence

Disease

West Jakarta North Jakarta Denpasar Indonesia

2007 2010 2007 2010 2007 2010 2007 2010

Cancer 3.8 n.d. 8.7 n.d. 0.5 n.d. 4.3 n.d.

Diabetes mellitus 1.9 n.d. 2.8 n.d. 2.0 n.d. 0.7 n.d.

Heart disease 3.3 n.d. 11.6 n.d. 2.6 n.d. 7.2 n.d.

Hypertension 23.8 n.d. 28.7 n.d. 25.8 n.d. 31.7 n.d.

Stroke 8.5 n.d. 1.1 n.d. 0.4 n.d. 8.3 n.d.

Mental emotional disorder 11.0 n.d. 14.0 n.d. 3.7 n.d. 11.6 n.d.

Mental illness 0.3 n.d. 17.7 n.d. 0.1 n.d. 4.6 n.d.

Acute respiratory infection 9.1 n.d. 10.7 n.d. 1.0 n.d. 8.1 n.d.

Pneumonia 0.3 n.d. 0.5 n.d. 0.3 0.31a 0.6 n.d.

Tuberculosis 0.4 1.03a 1.1 1.03

a 0.2 0.31

a 0.4 n.d.

Diarrhoea 6.3 n.d. 10.2 n.d. 4.2 n.d. 9.0 n.d.

a. Basic Health Survey (Riskesdas), 2007 and 2010.

20

Policy domain 1: Physical environment and infrastructure

The following indicators were selected for physical environment and infrastructure:

Access to safe water (%)

Access to sanitary toilet facility (%)

Access to sanitary toilet facility, by level of income (%)

Households using fuels, by type (%).

The status of those indicators is presented in table 10.

Table 10. Physical environment and infrastructure indicators

Indicator


2007 2010 2007 2010 2007 2010 2007 2010

Access to safe water (%) 56.0 87.0a 56.0 87.0

a 32.4 79.7

a 57.7 67.5

a

Access to sanitary toilet

facility (%)

66.6 82.7a 66.6 82.7

a 74.4 71.8

a 43.0 55.5

a

Access to sanitary toilet facility, by level of income (%)

Quintile 1 50.8 n.d. 49.7 n.d. 57.8 n.d. 25.1 n.d.





Households using fuels, by type (%)

Electricity 4.6

99.4a

4.6

99.4a

7.4

72.7a

1.9

60.0a LNG (gas) 29.5 29.5 47.3 10.6

Kerosene 60.8 60.8 38.1 36.6

Charcoal 0.2

0.6a

0.2

0.6a

0.1

27.3a

0.8

40.0a Wood 0.1 0.1 1.5 49.4

Other 4.8 4.8 5.5 0.8

a. Data from Riskesdas, 2010.

Policy domain 2: Social and human development

The following indicators were selected for social and human development:

Illiteracy rate by age group and sex

Percentage of births attended by skilled health personnel

21

Percentage of fully immunized children (12–23 months)

Moderate to severe underweight children (under 5 years)

Active tobacco smokers (over 15 years).


Table 11. Social and human development indicators

Indicator


2007 2010 2007 2010 2007 2010 2007 2010

Illiteracy rate by age group (years) (%)

20–29 1.7 n.d. 0.6 n.d. – n.d. n.d.

30–39 1.2 n.d. 1.1 n.d. 1.9 n.d. n.d.

40–49 2.9 n.d. 2.3 n.d. 15.1 n.d. n.d.

50–59 6.9 n.d. 12.0 n.d. 20.8 n.d. n.d.

60+ 10.4 n.d. 9.1 n.d. 20.8 n.d. n.d.

Literacy rate by sex (% of total)

Male 34.1 98.5a 34.1 96.6

a 20.8 98.0

a

Female 65.9 93.6a 65.9 92.6

a 79.2 95.4

a

Births attended by skilled

health personnel (%)

98.7 95.8b 98.5 95.8

b 99.6 97.3

b 72.5 82.2

b

Fully immunized children (12–

23 months) (%)

38.9 53.2b 30.5 53.2

b 64.1 66.1

b 46.2 53.8

b

Moderate–severe underweight children (under 5 years)

Severely underweight 4.1 2.6b 3.1 2.6

b 2.9 1.7

b 5.4 4.9

b

Moderately underweight 9.2 8.7b 14.4 8.7

b 7.1 9.2

b 13.0 13.0

b

Active tobacco smokers (over 15 years) by sex

Total 23.9b 23.9

b 25.1

b 28.2

b

Male 62.7 59.3 46.9 55.7 54.1b

Female 2.7 3.7 22.0 4.4 2.8b

Active tobacco smokers by level of income (%)

Quintile 1 34.6 n.d. 30.9 n.d. 20.8 n.d. 29.0 27.2b





Sources: National Socioeconomic Survey (Susenas), 2007; Basic Health Survey (Riskesdas), 2007.

22

a. Badan Pusat Statistik (BPS) (Statistics Indonesia).

b. Riskesdas, 2010.

Policy domain 3: Economics

The following indicators were selected for the economics domain:

Proportion of population with income below $1 (PPP) per day

Percentage of households with access to credit or income-generating activities

Proportion of households in different accommodation types.


Table 12. Economics indicators

Indicator


2007 2010 2007 2010 2007 2010 2007 2010

Proportion of population

with income below $1

(PPP) per day

4.2 3.5a 14.8 3.5

a 2.4 4.0

a 5.2 13.3

a

% households with access

to credit or income-

generating activities

2.0 n.d. 2.6 n.d. 2.8 n.d. 5.3 n.d.

Proportion of households in different accommodation types

Self-owned 47.3 45.2b 45.4 45.2

b 47.5 60.2

b 79.1 78.0

b

Rented 39.3 40.6b 36.8 40.6

b 39.0 28.1

b 8.4 10.3

b

Not rented 13.0 – 17.2 – 13.5 – 12.3 –

Other 0.4 14.2b 0.6 14.2

b – 11.7

b 0.3 11.7

b

Source: National Socioeconomic Survey (Susenas), 2007.

a. Central Bureau of Statistics, 2010.

b. Susenas, 2010.

Policy domain 4: Governance

The following indicators were selected for the governance domain:

Allocation of government spending to health and other related social services:

o Total government health expenditure

o Ministry of Health budget

o General government expenditures on health as % of total

o Private health expenditure on health as % of total

o Expenditure on health per capita

23

Voter participation rate in local and national elections

Number of development projects planned and implemented with the community

Corruption index or measure.


Table 13. Governance indicators

Indicator


2007 2010 2007 2010 2007 2010 2007 2010

Allocation of government spending to health and other related social services:

Total government

health expenditure

Greater

Jakarta:

1.3 billion

Indonesian

rupees

85 848

million

Indonesian

rupees

18.34

billion

Indonesian

rupees

Ministry of Health

budget

2.5%

General government

expenditures on health

as % of total

51.3%

Private health

expenditure on health

as % of total

48.7%

Expenditure on health

per capita

Greater

Jakarta:

US$18.5

Greater

Jakarta:

US$18.5

US$46

Voter participation rate in

local and national

elections

70% 70% 70%

Number of development

projects planned and

implemented with the

community

Corruption index or

measure

Jakarta

4.06

Jakarta

4.06

Indonesia

4.57

Data collection and validation

Data collection for the Urban HEART pilot in North Jakarta, West Jakarta and Denpasar was

undertaken by the previous assessment team. No special effort was made to collect primary

data, and most of the data used were secondary data. The aim of using publicly available data

24

was to ensure the validity and representativeness of the data and information, analysis of

which would provide evidence for policy-making and decision-making processes. In reality,

the data derived from routine data collection were, in most cases, either not complete or

underreported.

Generally, data collected for the assessment of health equity was derived from publicly

available data sources, including:

Intercensal Population Survey (SUPAS), 2005

Indonesia Demographic and Health Survey, 2007

National Socioeconomic Survey (Susenas), 2007

Basic Health Survey (Riskesdas), 2007 and 2010

National Health Account (NHA), 2008

Local Government in Figures, 2008

Transparency International Indonesia, 2009.

With regard to qualitative data and information collection to obtain an overview of previous

Urban HEART pilot implementation, focus group discussions were organized in Jakarta and

Denpasar on 12 September and 28 September 2011, respectively. Each focus group

discussion was attended by 25 participants, mostly intersectoral officials. The discussions

were facilitated by a representative of the Indonesian Institute for Epidemiological

Development and Study. Five topics were discussed:

participants’ understanding of the concept of Urban HEART

role of teamwork in implementation of Urban HEART

roles and tasks of various stakeholders

indicators used

follow-up action.

The outcomes of the focus group discussions have been used in the consideration of specific

issues in this report. A summary of the outcomes can be found in annex B.

Urban Health Equity Matrix

Based on Urban HEART guidelines provided by the WHO Kobe Centre, the data collected

were processed and analysed, and transferred to the Matrix used to compare indicators both

between cities and within the city. Different colour codes were used according to the results

for each indicator, using different threshold values as a basis for comparison. The Matrix,

which is presented in annex C to this report, summarizes the performance of cities in the

selected domains and enables analysis of the comparative effectiveness of the policy and

programme interventions at city level.

25

Urban Health Equity Monitor

The Urban Health Equity Monitor is constructed to track the performance of health indicators

over time and to show the trends in the inequity situation between cities and within a city.

Figure 3 shows the trends in infant mortality rates in Greater Jakarta, Denpasar and Indonesia

as a whole, 1994 to 2007, based on the results of the Demographic and Health Survey. As can

be seen, rates for Jakarta and Denpasar are lower than for all Indonesia, though they are still

higher than the rate of 17 deaths per 1000 live births needed for Indonesia to attain its target

for MDG4 on reducing child mortality.

Figure 3. Infant mortality rates: Jakarta, Denpasar and Indonesia (1994–2007)

Resources used

On a trial basis, the Urban HEART pilot used resources from WHO through the APW

mechanism. US$ 10 000 were provided by WHO to implement Urban HEART and develop

response strategies to combat inequities identified between and within cities. So far, no

pipeline budget has been provided by national or local government for Urban HEART,

including for the pilot locations. However, the budget line for the Healthy Cities initiative

may be available to finance health programmes related to safe water supply, provision of

sanitation and other environmental health activities.


The implementation of Urban HEART in three cities in Indonesia was facilitated by the

National Institute of Health Research and Development in collaboration with the Healthy

Cities coordinating team. However, the output of Urban HEART needs to be followed up by

policy-makers. Action is required by the respective sectors and through intersectoral action,

based on the assessment results. Linkages should be made according to the coordination

required to address health inequity problems, for example through provision of safe water

supply. Intersectoral facilitation is also vital to address pressing health problems such as

dengue haemorrhagic fever, which is the subject of a government control programme (table

14).

26

Table 14. Healthy Settings for dengue haemorrhagic fever control programme

Healthy settings for

control of dengue fever Areas of work Multisectoral responsibilities

Settlements Houses, apartments,

habitations

Municipal offices for environmental

health, development companies, public

works, government departments for

building and development guidelines

Educational institutions Schools, campuses,

religious centres,

colleges

Government education agencies,

administrations of educational and

religious institutions

Workplaces Government and

private offices

Government agencies for trade and

industry, occupational guidelines

Public places Markets, malls,

terminals, stations,

airport, harbours,

social locations, hotels

City governance, relevant

administrations for public locations

Food establishments Restaurants, canteens,

catering services

Relevant municipal administrations and

offices of food-related establishments

Health facilities Hospitals, health

centres, delivery

facilities, pharmacies,

clinics

Ministry and departments of health,

private institutions

Sports facilities Sports halls, playing

fields, stadia

Sports ministry, private institutions

Hindering factors

As previously mentioned, health inequity is determined by multiple factors involving many

sectors. Therefore, assessment for health equity should be built on the basis of a range of

intersectoral components, and intersectoral coordination is key to the success of any health

equity programmes. That coordination should be in place from the start of the planning

process, and analysis of health-related data should be the “cement” that binds together

integrated intersectoral planning. The alternative is disintegrated, sector-specific planning,

with the potential for duplication of action and piecemeal implementation.

Lessons learnt

The Healthy Cities initiative could not be successfully undertaken by the health sector alone.

Comprehensive planning is therefore needed for implementation of Urban HEART, as the

assessment indicators used are multisectoral, requiring a comprehensive response.

Sustainability of that response depends on a high level of multisectoral commitment to an

improvement in health equity. Community involvement at grass-roots level is another key

requirement for success.

27

5.3 Response prioritization phase

Stakeholder engagement

Health inequity has been a long-standing issue, regardless of Urban HEART. It is a human

rights matter. In recognition of that, engagement of stakeholders in Urban HEART needs to

be widened to other cities, and efforts made to strengthen and enhance utilization of the tool

in line with Healthy Cities policies and strategies.

Prioritization of health equity issues

Health equity issues need to be given high priority in urban development and other

programmes, including the National Long-Term Development Plan. Various objectives of the

Ministry of Home Affairs are pertinent to raising the profile of health equity from an

intersectoral viewpoint:

Objective: competitiveness

Improve workplace and worker welfare

Embrace a multi-ethnic and multicultural approach to sustainable development

Promote a healthy investment climate

Improve urban resources and infrastructure, inter-city and city-village linkages

Adopt an environment-friendly philosophy

Promote efficient use of energy

Develop residential areas without slum growth

Provide basic services, including adequate transport.

Objective: equity and fairness

Ensure balanced growth of cities

Promote inter-city economic linkages

Undertake proper urban planning

Consider the role and function of small and medium-sized urban settlements

Ensure the urban environment is conducive to economic activities

Revitalize cities and towns through zoning and functional definition

Provide public facilities and services.

Prioritization of interventions and strategies

Prioritization of interventions is based on the mechanism of the Development and Planning

Forum, which is a system of bottom-up planning through the participation of a wide range of

stakeholders from community, through village, to central level. In line with the Healthy

Cities initiative, efforts are concentrated on the development of health centres in different

urban locations and the provision of health services for urban slum areas. National guidelines

28

for the latter are being prepared for publication and dissemination, and will include the Urban

HEART concept.

Development of proposal or action plan

The specific proposal or action plan is undertaken by a community working group at village

level. In Jakarta action is at the level of the family peace neighbourhood, which is a

subvillage community organization. The Healthy Cities initiative includes creation of a

working group for community self-assessment to help identify community needs and actions

required. A plan of action is set up on that basis.

Resources used

Human, financial and material resources were provided by local government. In addition,

resources for implementation of the Urban HEART pilot were provided by WHO, though

there was no budget for follow-up action; any resources for such action were expected to

come from the city budget.


As the Urban HEART concept is intended to guide policy- and decision-makers, a facilitating

factor is ensuring that the results are used as evidence by policy- and decision-makers. Social

acceptance of the measures to be implemented is also crucial. When undertaking trial

activities under Urban HEART, it is essential to build the capacity of concerned personnel at

city level, though to some extent that has been provided for in the Healthy Cities initiative.

Hindering factors

Introduction of a new concept such as Urban HEART requires that efforts are made to create

an environment conducive to the success of the operation. Piloting Urban HEART is only the

starting point, and needs to be followed by further action, including disseminating the results

for replication in other areas. In this connection, efforts are needed to widen social

acceptance and knowledge of the tool. Training workshops would help introduce the concept

to relevant officers and stakeholders and build capacity to sustain the momentum of

activities, and this eventuality has been provided for by WHO.

In addition, disaggregated data for health outcome indicators, and for physical, social,

economic and governance indicators, are still difficult to obtain. The data used are mostly

secondary data from various surveys or institutions. Community-based data may differ from

routinely collected facility-based data, leading to some disagreements between government

officials.

A further problem has been delays in documentation and evaluation of the Urban HEART

pilot, leading to a slowing of momentum and a decline in stakeholder interest. Several of

those involved have moved to different posts.

Lessons learnt

The Urban HEART pilot was undertaken by the National Institute of Health Research and

Development along with City Health Office staff, in accordance with the Urban HEART

29

guidelines provided by WHO. The results presented to the intersectoral team of the Healthy

Cities programme demonstrated the value of support from local government and other related

sectors and the commitment of all stakeholders. There was agreement that the exercise would

improve the process of identifying interventions through the sharing of successful

experiences among sectors and the active participation of local community groups. Problems

identified included the extent to which the principle of equity can be extended to illegal

residents, and illegal occupancy of public land. Other issues for further discussion include the

experience of local government in implementing free health care for the poor, the distribution

of cheap rice and cash transfers, and free contraception for the poor, all of relevance to

closing the health equity gap.

5.4 Policy development and programme implementation phase

Policy uptake and development

A number of policies have been developed with regard to urban health equity. After much

debate, the House of Representatives finally agreed to enact the Social Security Providers

(BPJS) Law on 28 October 2011, thus providing full health and job protection for all

Indonesian citizens. The new law requires state-owned insurance companies PT Askes, PT

Jamsostek, PT Taspen and PT Asabri to become non-profit institutions working directly

under the President’s supervision, with the last three companies merged into one. The law

will be effected in 2014.

Other relevant regulations and decrees include:

Law No. 32/2004 on decentralization of local government;

Government Regulation No. 38/2007 on distribution of tasks among central,

provincial, and district or municipal governments;

Common Rule No. 34/2009 between the Ministry of Interior and the Ministry of

Health about the implementation of the Healthy Districts and Healthy Cities

initiatives;

Ministry of Interior Regulation No. 57/2010 on guidance for city service standards;

Ministry of Health Decree No. 828/2008 on guidelines for minimum service standards

for health at district and city level, with 18 indicators;

Jakarta Government Rule No. 4/2009 on provincial health systems.

Programme development and implementation

Programme development includes health inequity reduction measures based on the

Development and Planning Forum mechanism and discussed through the Regional

Development Planning Agency (Bappeda) and approved by local parliament. The main

priority of efforts to reduce health inequity is to increase access to and quality of community

health services, especially for poor, disadvantaged and marginal populations within the city.

The implementation of activities is carried out at the community village level through

intersectoral collaboration and in coordination with the City Health Office.

30

Status of implementation

Several site visits were undertaken to West Jakarta, North Jakarta and Denpasar to inspect

selected activities that are attempting to upgrade local community facilities and reduce health

inequities. Relevant ongoing activities include:

City of West Jakarta

A site visit to the village of Duri Kosambi in Cengkareng subdistrict, West Jakarta, was

undertaken to look at the community village activities related to reduction of health

inequities, with intersectoral government support. The following are examples of actions

undertaken.

For sanitation and sewerage improvement, a community water and latrine project was

organized by the community working group for Healthy Cities at village level at Duri

Kosambi village.

[Picture 1: Community latrine and piped water]

[Picture 2: Village housing]

A healthy and clean environment was promoted through improvements to small roads

and alleys within crowded housing areas. Stagnant water was drained away and the

environment improved by planting greenery in both public areas and individual

compounds.

[Picture 3: Improved environment with pavement and greenery]

[Picture 4: Plan of latrine with communal septic tank]

To improve nutrition for children under 5 years of age, local soybean was mixed with

fish to make a more nutritious food.

The village community has also developed communal, concrete septic tanks, each

covering nine households. This helps avoid water pump contamination by sewage in

crowded housing areas.

The National Programme on Community Empowerment, inaugurated in 2009, helped

rehabilitation of village roads in collaboration with local communities.

City of North Jakarta

A site visit to Rawa Badak village on 24 October 2011, organized by the Jakarta Provincial

Health Office along with North Jakarta City Health Office, looked at current activities related

to health inequity problems. Field visits were undertaken to community villages to witness

the following activities.

A green environment programme, similar to that carried out in West Jakarta, was put

in place, providing benefits in a coastal area with relatively high daytime

temperatures.

[Picture 5: The Healthy Cities evaluation team visits Rawa Badak village]

31

An integrated health post was set up. In addition to the regular activities of the health

post, a number of community-based income-generating activities were organized,

some of which are described below.

A scheme was put in place to recycle both organic and inorganic garbage, including

plastics. The recycling was carried out by the village women’s working group, which

creates such products as handbags, mats and children’s toys.

Under the aegis of the integrated health post, a healthy city working group was set up

at village level. Its main function was to organize regular development planning

forums for Rawa Badak village. The forums would identify community problems and

needs requiring a multisectoral approach for their resolution in line with local and

national policies.

In addition, a bank was set up in a community village at Cilincing for people to

deposit various types of garbage for recycling, including processing green vegetable

waste into fertilizer by machine; shredding plastic bottles and glass materials into

smaller pieces for recycling; and making useful products, such as tables or plastic

bags, from recycled materials. Other activities associated with the garbage bank

include fish farming and growing herbs. Management of the bank uses a simple

computerized administration system.

[Picture 6: Processing green matter into fertilizer]

[Picture 7: Shredding plastic and glass]

[Picture 8: Various items made from recycled materials, including plastics]

[Picture 9: Fish farming]

[Picture 10: Garbage bank office]

The system flow for the bank comprises garbage detection; collection; processing;

and marketing. Members pay a basic price of 1500 Indonesian rupiahs per kilogram

of garbage. A borrowing system is also in place for members, giving benefits of better

garbage management, income regeneration, and environment-friendly recycling of

organic and inorganic materials at community level. The bank started with 70

members, and current membership is over 500.

City of Denpasar

A site visit was undertaken to Pemecutan Kaya in Denpasar to look at the community village

activities related to health inequity reduction. Ongoing activities are described below.

To provide community sanitation, the Public Works and Environment Office,

Denpasar, set up a sewerage system for households in poor and crowded living

conditions. The infrastructure aimed to protect household in slum areas against

sewage contamination.

[Pictures 11 and 12: Sewerage system established in community sanitation project]

32

For sanitary garbage management, a project is being developing to assist garbage

disposal and recycling. This involves construction of a facility in Denpasar for

processing garbage and recycling it into useful products. All organic and inorganic

garbage will be collected and separated into different categories, and processed

according to the objectives of the programme, which is an intersectoral initiative

aiming to improve equity.

[Pictures 13 and 14: Construction of infrastructure for garbage disposal and

processing]

An integrated community sanitation programme is being implemented to remove

sewage from family housing using a solar-powered system. Again, the programme

adopts an intersectoral approach.

[Picture 15: Integrated community sewage disposal programme]

While the above-mentioned programmes fall under the Public Works and Environment

Office of the City of Denpasar, they are organized and coordinated by the community village

working group under the Healthy Cities initiative.

Other health equity-related projects in Denpasar include a healthy housing and environmental

improvement project, and free health service provision for poor populations under a health

maintenance scheme.

Sustainability measures

Efforts have been made to ensure the sustainability of ongoing activities, as follows:

The ongoing activities are being carried out by the concerned subvillage community

working groups, as proposed on the basis of the community needs assessment through

a self-assessment survey.

Proposed activities are submitted through a given procedure, depending on the cluster

in which they fall, for consideration by the City Health Office or the Local Planning

Board, or at national level if necessary. Sustainability considerations should be

included within the proposal.

Planning is on an annual basis according to the mechanism of the Development and

Planning Forum, which is standard procedure for bottom-up planning in Indonesia,

starting from the community village level and proceeding through subdistrict, district

or city, province and finally central level.

The district and city levels are mainly responsible for ensuring the sustainability of

activities according to Law No. 32/2004 on decentralization of local government.


The urban health equity assessment is influenced by many factors, including the above-

mentioned procedural issues. Other facilitating factors include:

33

The assessment requires mobilization of human resources with the capacity to

undertake and manage the process of assessment, including the capacity to interpret

the findings through application of the Urban Health Equity Matrix.

As Urban HEART is a relatively new tool for most of the stakeholders, adequate

explanation of the methodology and the benefits of using the tool is needed.

The results of the assessment need to be discussed and analysed and response

strategies proposed to deal with the issues of health inequity revealed by the

assessment.

All of these matters require support and facilities – not only through mobilization of

human resources, but also financial support and government commitment to the use of

the tool by decision-makers.

Hindering factors

The application of Urban HEART requires a certain level of competency and supportive

conditions, absence of which can hinder the process:

The assessment needs to be undertaken by a cohesive intersectoral team who have a

clear understanding of the tool before the assessment is undertaken.

Each related sector should be clearly informed and accept their role, either in

assessment or in providing response activities for inequity reduction. Preconditioning

is needed in readiness for implementation of Urban HEART.

Positive perception and acceptance by government officials and related stakeholders,

as well as community involvement in the utilization of Urban HEART, are extremely

important for further actions.

Support and cooperation among health and other programmes is also required,

organized under strong leadership and displaying good governance.

The assessment results and responses need to be presented to and agreed upon by key

intersectoral decision-makers and stakeholders.

Lessons learnt

The support and commitment of the city authorities and local government, including

at sectoral level, is key to the effectiveness and success of any programme on health

inequity reduction.

It is advantageous to improve the process of identifying interventions through the

sharing of successful experiences by each sector, and active participation of local

community groups.

Specific problems may arise and need to be taken into account to ensure the success

of a health equity programme, such as the presence of illegal migrants, who do not

have the rights and access of ordinary citizens and may illegally occupy public land.

The availability of sound data and information determines the sensitivity of the

assessment and specificity of the provision of responses.

34

5.5 Impact and outcome evaluation

Benefit: to learn how to assess the health inequity situation systematically, and to focus on

problems related to health inequity.

Challenges: Lack of availability of data, inadequate budget allocation and prioritization,

inadequate attention to monitoring and assessing the impact of interventions.

Monitoring and evaluation mechanisms

The implementation status of health equity assessment and efforts to respond to inequities

need to be regularly monitored and evaluated according to timeframe, location and human

resources.

Efforts to monitor the responses to the assessment results should be undertaken by the

relevant working unit using the appropriate mechanism.

Health-related sectors should be familiarized with the selected indicators for

assessment of health inequity and the selected strategies for responses.

Evaluation of health inequity and responses should be built into the available system,

with emphasis on the use of the above-mentioned indicators.

Collection of specific data for monitoring and evaluation of certain aspects of health

inequity needs to be undertaken.

Improvement in awareness raising and priority setting

With regard to improvement of awareness raising and priority setting, the evaluation finds

that:

In theory, using the Matrix for targeting and prioritization should be easier for those

indicators where the widest gaps are apparent.

More stakeholders should be made aware that health inequity is a result of inadequate

social and economic conditions.

Intersectoral collaboration on health determinants, such as those related to social and

economic conditions, public works, the environment, and governance, should be

enhanced.

Scaling up Urban HEART

The Ministry of Health has included the Urban HEART concept in guidelines for

strengthening primary health care for slum and peripheral areas and poor and

disadvantaged populations.

Dissemination of Urban HEART guidelines is essential, as Indonesia currently has 98

cities that are categorized as being at the same level as districts.

Urban HEART has the capacity to promote and improve implementation of the

Healthy Cities initiative in Indonesia.

35

Additional policies and programmes

As health equity is a dynamic human issue, there is scope for extending or adapting it in

accordance with national and subnational (decentralization) policies and regulations,

including:

The Social Security Providers (BPJS) Law, passed by the House of Representatives

on 28 October 2011, which allows full health and job protection for all citizens. This

national law will be effected in 2014.

Jakarta Government Rule No. 4/2009 on provincial health systems, which covers the

whole rule for health system development programmes and services to be followed by

health and health-related sectors.

The policy on free health care for the poor, implemented in Jakarta and Denpasar.

Intersectoral action on health

As mentioned above, documentation and evaluation for Urban HEART, undertaken in Jakarta

and Denpasar, revealed several examples of intersectoral action for health, including:

Action at community village level in West and North Jakarta

Green environment activities in West and North Jakarta

Community sanitation project and sewerage development in Denpasar

Integrated community sanitation project using solar power, Denpasar

Garbage management and recycling in Denpasar

Health insurance with free services for the poor in Jakarta and Denpasar.

Intervention outcomes on health and health equity

Life expectancy at birth has been increased significantly, as shown by the health

outcome indicators.

There has been a decrease in the infant mortality rate due to interventions in the health

and health-related sectors.

The maternal mortality ratio has also moved towards the MDG target.

Data show a trend towards improvement of almost all selected outcome indicators on

a year-to-year basis.

6. Summary of key lessons, impacts and outcomes, and

recommendations

6.1 Lessons learnt

Key lessons learnt from the overall process of the piloting experience, and issues to be

considered in future implementation of Urban HEART, include the following:

36

Health inequity is actually a long-standing issue that has been identified in a number

of international initiatives and forums, including Health for All by the year 2000, and

other outcomes of the International Conference on Primary Health Care, Alma-Ata,

1978.

The piloting of Urban HEART has provided an additional effective tool for the City

Health Office in its efforts to accelerate health inequity reduction in various sectors in

the coming years.

The tool itself is not entirely new but the systematic and practical approach makes it

very user friendly. The indicators selected for implementation of Urban HEART in

2009 have been assessed during the evaluation process and will be retained

unchanged.

A key to the success of the assessment is the availability of accurate and relevant data,

starting from community data at village level, through subdistrict to city level.

Where data are not available, the assessment should be ready to undertake a simple

rapid survey for collection of relevant data and information.

The response strategies prompted by Urban HEART may be difficult to incorporate

into the decision-making process due to sectoral self-protection and conservatism.

Policy-makers at city level should show guidance and leadership in resolving this

problem.

The experience of Urban HEART implementation in three pilot cities could play an

important role in inspiring decision-makers and health-related stakeholders to gear up

policies for better health equity in the 98 cities of Indonesia.

As health is related to almost all aspects of human life, Urban HEART could be

modified to embrace other sectors, depending on their suitability for such an

approach.

6.2 Key impacts and outcomes of the piloting experience

Given the importance of urban health, it is important to organize intersectoral

responses towards health challenges in towns and cities. Responses do not lie with the

health sector alone but with decisions made in other sectors and areas: in local

government, education, urban planning, physical infrastructure, and access to social

and health services.

The concerned professionals have to face the challenges of overloaded water and

sanitation systems, polluting traffic and factories, lack of space to walk or cycle,

inadequate waste disposal, and crime and injury.

The Urban HEART pilot experience has opened up opportunities to improve

intersectoral collaboration for health inequity reduction.

More government officials and stakeholders now have a better understanding of

health inequity problems and an appropriate tool to respond to those problems

through community action and support, and intersectoral collaboration.

37

The availability of high-quality, disaggregated data and information remains a key

problem for assessment and formulation of responses. However, Indonesia has long

experience of undertaking self-assessment, including for identification of needs at

community level.

Urban HEART has been perceived as having a close connection with health policy

and the Healthy Cities and Healthy Districts initiatives in Indonesia. Urban HEART is

recognized as an improved approach and tool for health inequity reduction and a vital

component of any measures to improve urban health. It will be incorporated in the

new guidelines for primary health care in slum areas.

The Social Security Providers (BPJS) Law, which will become effective in 2014, will

be an important tool in enabling full health and job protection for all citizens of

Indonesia.

6.3 Recommendations

The six steps of the Urban HEART process, provided within the guidelines, need to

be carried out consistently and with strong leadership.

Quantitative data collection for assessment may need to be combined with qualitative

data collection to assist evidence-based policy-making.

As Urban HEART cannot be implemented by the health sector alone, its application

should be coordinated by a suitable unit to facilitate intersectoral action at city level.

In the case of Jakarta and Denpasar, the Bureau of Social Welfare and the Local

Planning Board offer suitable focus points.

As the Healthy Cities initiative has been in place in Indonesia over a long period, the

application of Urban HEART needs to be modified according to the existing

Indonesian Healthy Cities approach to ensure its convergence and sustainability. To

assist this, functional alignment should be considered between the Healthy Cities

team and the Urban HEART team.

The response strategies for reduction of health inequities should be a part of the wider

social and development agenda for improvement in the quality of human life. The

success of selected priority strategies depends on how best social determinant factors

are identified and analysed in relation to the health inequities occurring in a particular

community.

Use of Urban HEART should be promoted and disseminated widely in all (98) cities

in Indonesia. This includes development of Indonesian Urban HEART guidelines and

provision of training for city support teams (which, as stated above, may comprise the

Healthy Cities team).

Urban HEART should be introduced into the decision-making processes at an early

stage to ensure acceptance of the results.

Health equity is a never-ending issue. It should always be developing within a real

context and in line with national and local development policies and strategies, as

38

well as with their existing programmes. At the moment, Urban HEART has been used

to some extent in the formulation of public health policy, implementation of healthy

city projects, and attaining the MDG targets in cities.

To be more relevant, outcome indicators should use data from higher administrative

levels (for example province level).

Adequate external resources need to be provided by WHO, especially for

socialization of Urban HEART implementation and development of an established

model suitable for Indonesia conditions in order to ensure sustainability.

Strong support should be mobilized through a WHO collaborative programme with

the Government of Indonesia on urban health and Healthy Cities.

Relevant source materials

Central Bureau of Statistics. 2008. North Jakarta in figures.

Central Bureau of Statistics. 2008. West Jakarta in figures.

Central Bureau of Statistics and Macro International. 2007. Indonesia Demographic and

Health Survey. Calverton, Maryland, USA.

Denpasar City Health Office. 2010. Plan of actions: Denpasar healthy city 2011–2015.

Denpasar City Health Office. 2011. Denpasar health profile 2010.

Government of Indonesia. 2004. Law No. 32/2004 on decentralization of local government.

Government of Indonesia. 2007. Government Regulation No. 38/2007 on distribution of tasks

among central, provincial, and district or municipal governments.

Government of Jakarta Special Province. 2009. Local Government Rule (Perda) No. 4/2009

on Jakarta provincial health system.

Government of Jakarta Special Province, Health Office. 2009. Jakarta Province health

profile 2009.

Ministry of Health. 2008. Rule No. 741/2008 on minimum service standards for health at

district or city level (including 18 indicators).

Ministry of Health. 2009. National health system.

Ministry of Health, Directorate of Community Health. 2005. City health centres:

implementation guidelines.

Ministry of Health, Directorate of Community Health. 2006. Introduction of urban health.

Ministry of Health, Directorate of Community Health. 2010. Implementation of city health

services.

Ministry of Health, Directorate General of Public Health. 2011. Results of city health centres

pilot in three provinces (East Java, Bali and South Sulawesi).

39

Ministry of Home Affairs. 2010. Regulation No. 57/2010 on guidance for city service

standards.

Ministry of Home Affairs and Ministry of Health. 2005. Guideline for implementation of

Healthy Districts and Healthy Cities. Common Ministry Rule No. 34 of Ministry of

Home Affairs and No. 1138 of Ministry of Health, 2005.

National Institute of Health Research and Development and Ministry of Health. 2008. Basic

Health Survey (Riskesdas): 2007 report for Indonesia.


Health Survey (Riskesdas): 2007 report for Province of Bali.


Health Survey (Riskesdas): 2007 report for Province of Jakarta.

WHO Kobe Centre. 2008. Urban HEART (Health Equity Assessment and Response Tool).

40

Annex A. Minimum service standards on health at district and city levels (Ministry of

Health Rule No. 741/2008)

A Basic health service indicators Target 2010 Target 2015

1 Coverage of antenatal care (fourth visit) 95%

2 Coverage of pregnancy complications handled 80%

3 Coverage of deliveries assisted by personnel with midwife

competencies

90%

4 Coverage of postnatal service 90%

5 Coverage of neonatal cases handled 80%

6 Coverage of neonatal visits 90%

7 Coverage of universal childhood immunization by villages 100%

8 Coverage of health services for children under 5 90%

9 Coverage of additional food for poor children (aged 6–24

months)

100%

10 Coverage of children with moderate to severe

malnourishment receiving health care

100%

11 Coverage of primary school children receiving health

screening

100%

12 Coverage of active family planning participants 70%

13 Coverage of case detection and disease treatment 100%

14 Coverage of primary health care for the poor 100%

B Referral of health service

1 Coverage of referral health services for poor patients 100%

2 Coverage of first-level emergency services 100%

C Epidemiological investigation and containment

measures for emergencies

1 Coverage of village emergency events with epidemiological

investigation within 24 hours

100%

D Health promotion and community empowerment

1 Coverage of active village alerts 80%

41

Annex B. Summary of results of focus group discussions on Urban HEART

Discussion topics /

guiding questions

North and West Jakarta responses

12 Sep 2011

Denpasar responses

28 Sept 2011

A. Participants’ understanding of Urban HEART concept

What is your level of

understanding of

Urban HEART?

It is a community effort, as opposed to

government work units

It is an effort to improve health status

and focus on improvement of

environmental factors

It is an instrument to improve

community status at city level, with an

emphasis on less fortunate community

groups

It is a WHO concept to find out

information about the balance of health

for policy-making – “what and how to

do”

Most participants knew nothing about

Urban HEART before explanation

Institutional representatives who were

invited were not familiar with the term

Urban HEART

They were, however, familiar with

health service equity and intersectoral

collaboration on health

Which government

work unit was

involved in previous

Urban HEART?

City of Jakarta Health Office

Public Works and Environment Office is

responsible for physical infrastructure

and health & environment programmes,

including community sanitation

Economic, sport, social welfare, family

planning departments

City of Denpasar Health Office

Public Works and Environment Office is

responsible for physical infrastructure

and health & environment programmes,

including community sanitation

B. Potential for teamwork on Urban HEART

Any special team to

handle Urban

HEART?

There is no special team to handle Urban

HEART in Jakarta

However, the Healthy Cities team has an

intersectoral basis and could contribute

Some team efforts to combat health

inequity could be of assistance,

including rice for the poor, health

management and care for the poor,

working group for the poor

There is a lack of such expertise in

Denpasar

The Healthy Cities team, however, may

have the intersectoral potential required

What are the job

requirements for

working units within

the established team?

Most sectors have issues of health equity

that are relevant to Urban HEART

For example, the family welfare

empowerment unit has a function to

enhance health lifestyles

There are many examples of community

team participation on health matters

Regional work units have synergistic

Working unit themes:

Landscape and housing issues: take

account of populations without housing,

poor people

Family planning: relevant issues include

empowerment of women, free family

planning

Tourism: include hotel and tourism staff

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Discussion topics /

guiding questions


12 Sep 2011

Denpasar responses

28 Sept 2011

aspects

Any working unit will have a role to

play in health inequity reduction, the

question is whether they are given an

appropriate role to play and a functional

mandate

in matters of disease and illness control

Social welfare: consider the unemployed

and poor, and poor housing conditions

Any regular meetings

among team

members?

Team meetings are held for specific

purposes, for example healthy city

forum, with exchange of information

and action plan if needed

Each working unit applies its own

mechanism

Regular meetings of the healthy city

forum, exchange information and

develop action plan if needed

Tasks distributed according to the main

job responsibilities and indicators

Community role and involvement in

meetings

Three-monthly monitoring and

evaluation

C. Roles or tasks of stakeholders

Any activities carried

out relevant to Urban

HEART?

Each unit carried out their own roles in

terms of given activities according to the

established plan of local government,

including community village alert

These activities are coordinated and

implemented at community and

subvillage level

Activities have been undertaken prior to

the introduction of Urban HEART,

including community sanitation and

garbage disposal and recycling projects

These activities are usually well

coordinated

Meetings are held for exchange of

information and experiences

Any focus areas for

application of Urban

HEART in your area,

and what criteria are

used?

The areas of work related to Urban

HEART are:

Sanitation and garbage disposal

Environment, green projects

Community village alert

Integrated health post, including

nutrition

Health facilities, including hospitals

Transport, tourism, insurance of visitors

D. Indicators used

Source of budget for

activities related to

Urban HEART?

Source of budget for activities related to

Urban HEART is mostly from local

budget

Special budget for health services and

treatment of the poor covered by local

insurance scheme

Source of budget for activities related to

Urban HEART is mostly from local

budget

Special budget for free health care and

treatment for the poor is covered by

local government

Indicators used in

relation to working

Three aspects of measurement for slum

areas, namely population, housing,

Implementation status of community

sanitation, including integrated septic

43

Discussion topics /

guiding questions


12 Sep 2011

Denpasar responses

28 Sept 2011

units (other than

health sector) of

relevance to Urban

HEART?

environment

Indicators relate to population density,

governance, housing construction and

ventilation, road conditions, sewage and

garbage disposal

Other indicators may refer to

distribution of rice to the poor,

achievement of MDGs

tank

Sustainability of project maintained by

local community

Active role of community in health

equity matters

Indicators for disadvantaged groups,

including distribution of rice to the poor,

achievement of MDGs, free health care

for the poor

Each related unit used their own

indicators to measure their targets

What sort of data used

for measuring

programme

indicators?

Regular reports

Ad hoc field monitoring

Statistics Office data

Regular reports

Ad hoc field monitoring

Statistics Office data

E. Follow-up action

How will follow-up

action plans and

budgeting be

undertaken with

regard to Urban

HEART?

As a formal government mechanism, the

working unit programmes related to

health equity should have their

respective plans for follow-up

The development and planning forum

can function as the first step to prepare

responses to reduce health gaps,

integrate resources, and gather data for

submission to higher levels

The village community working group

is the implementation unit for follow-up

actions

The problem remains of development

planning coordination between sectors

and departments due to

compartmentalized institutional thinking

A new or special team is not necessary

All working units have their own

follow-up planning

Local planning bodies deal with slum

areas, including where migrants are

illegally occupying land

Development and planning forum could

integrate resources and gather data for

sustainable follow-up actions

Development and planning forum could

instigate intersectoral action, depending

on the involvement of related sectors

[Picture 16: Focus group discussion in Jakarta health office, 12 September 2011]

[Picture 17: Focus group discussion in Denpasar health office, 28 September 2011]

44

Annex C. Urban Health Equity Matrix

45

Documents

Report on documentation and evaluation of Urban HEART pilot in … · 2018. 12. 13. · 6 local government officials, educationalists, urban planners, engineers and those who determine